Medical imagery for the field therapist
Medical Imagery
for the Field
Therapist
●●●
Traumatic Conditions
Charlen Berry B.Sc., CAT(C), DO(Qc)
Certified Athletic Therapist / Osteopath
EATA Buffalo 2013
Charlen Berry, January 2013,
EATA Conference, Buffalo
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Medical imagery for the field therapist
Why do we need to know ?
Pertinent information about the patient, past
and p
present history
y
Safety (2 aspects)
Better understand the tests, the views, the
healing processes and prescription guidelines
Which tests are most appropriate?
Post--concussion symptoms
Post
Communication and collaboration
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What do we need to know ?
80% of imaging in MSK conditions are
b i radiographs,
di
h
basic
Basic reading of X
X--Rays
Implications of different fractures
Basic knowledge on available tests
Knowledge of prescription guidelines
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Medical imagery for the field therapist
How do we get the knowledge
Presentations
Books & articles
Internet
Specific courses
References at the end of the presentation
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Medical imagery for the field therapist
Why ?
To have pertinent information in
the patient file at the beginning
of the season
Read the reports
See the images (radiology)
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Patient’s file:
Read the reports / See the images
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Medical imagery for the field therapist
HISTORY OF THE PAST
Imagery was done
W5 R
‰ Why?
‰ What for?
‰ When?
‰ Where?
‰ Who?
RESULTS ?
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HISTORY OF THE PRESENT
Foot or ankle ?
Standard views?
– What are they?
– Ankle: AP, LAT,
– Knee: AP, LAT,
Specialised views?
– Oblique views of the fibula?
– Plantar flexion
– Dorsiflexion
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Medical imagery for the field therapist
WHAT IS MEDICAL
IMAGING
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RADIOLOGY
Branch of medicine
concerned with
di
ti substances
b t
radioactive
including XX-Rays,
radioactive isotopes
and the application of
this information to the
prevention, diagnosis
and treatment of
disease.
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Medical imagery for the field therapist
MEDICAL IMAGING
Radiographs (simple films)
Contrast enhanced radiographs
Computerized tomography
Nuclear imaging
Magnetic resonance imaging (MRI)
Sonography (US)
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RADIODENSITY
composite shadowgrams representing the sum of the densities
SquireLF,, Novelline RA,
SquireLF
Physical qualities of an object
that determine how much
radiation it absorbs from the X
X-Ray beam.
Determined by its composition
(anatomical weight) and
thickness
Radiopaque / Radiodense
Radiotransparent / Radioluscent
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Medical imagery for the field therapist
MAJOR PHYSICAL DENSITIES
AIR :
Black (lungs, stomach, digestive tract)
FAT
FAT:
Gray--Black (more radiodense than air)
Gray
WATER: Grey (fluids, blood, muscles, tendons…)
BONE:
White (the most radiodense substance of
the body, teeth are whiter because to their
calcium content))
CONTRAST MEDIA:
HEAVY METAL:
Bright white outline
Solid white
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MAJOR DENSITIES
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Medical imagery for the field therapist
EXTERNAL DENSITIES
BARIUM
METAL
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SYSTEMATIC APPROACH TO
READING AN XX-RAY
A:
Alignment
B:
Bone density
C:
g spaces
Cartilage
S:
Soft tissues
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Medical imagery for the field therapist
ALIGNEMENT
General architecture
Size
Appearance
Accessory bones
Congenital & growth
anomalies
Post--traumatic
Post
modifications
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AP- ALIGNEMENT
APspinous process
1 facet sub-luxation
Anterior dislocation
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Medical imagery for the field therapist
LAT CERVICAL
Alignment, 3 lines
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BONE DENSITY
Normality: Sufficient contrast between the
skeleton and soft tissues and between
cortex and medullary center
Lost: osteopenia
osteopenia,, osteoporosis,
osteomalacia
Increase: osteopoikilosis
osteopoikilosis,, osteopetrosis
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Medical imagery for the field therapist
DISTORTION
shape or size
The pathology should
be right in the middle
of the film
X-rays will increase
the size from 0 to
30%
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OTHER RADIOLOGIC EXAMINATIONS
With contrast
A th
h , myelography,
l
h , arteriography…
t i
h …
– Arthrography,
Arthrography
myelography
arteriography
CAT scan, CT scan
– Axial tomography assisted by computer
Nuclear imaging
– Bone scan, ‘’‘’scintigraphie
scintigraphie osseuse
osseuse’’’’
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Medical imagery for the field therapist
WITH CONTRAST
Arthro MRI
Arteriography
Myelography
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Computer assisted tomography
(CAT Scan)
X-Ray merged with computer
technology
Provides geography of body structures
with much greater sensitivity than plain
films
X-Ray beam and detector system is
housed in a circular scanner (arc of
360º)
360
º)
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Medical imagery for the field therapist
CAT Scan / CT Scan
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CAT SCAN
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Medical imagery for the field therapist
BONE SCAN
Diagnostic use of radioactive
isotopes
Nuclear imaging of the skeletal
system
Radiopharmaceuticals that are
tissue--specific to bone are injected
tissue
intravenously
Patient placed under a scintillation
camera detecting radioactivity
Recording of the image is on an XXRay film
Highly sensitive but nonnon-specific
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MAGNETIC RESONANCE IMAGING
MRI
Does not involve ionizing radiation
Images are produced via the interaction of
tissue with radiofrequencies in a magnetic field
Radiowaves are pulsed to the patient, inducing
resonance among nuclei. Different tissues
resonate at different frequencies
frequencies.
When radiowaves are turned off, nuclei relax
and release the resonant energy, receivers
transmit the energy released to a computer.
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WHICH TEST IS THE MOST
APPROPRIATE
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Medical imagery for the field therapist
INDICATIONS FOR
CONVENTIONAL RADIOGRAPHY
Fractures
Periostitis
Arthropathy
Osteochondritis dissecans
Post--traumatic or congenital bony
Post
deformation
Muscular and tendinous calcification
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INDICATIONS FOR COMPUTERISED
AXIAL TOMOGRAPHY (CAT Scan)
Bone and soft tissue tumors
S btl or complex
l ffractures
t
Subtle
Intra--articular abnormalities
Intra
Detection of small bone fragments
Quantitative bone mineral analysis
– (osteoporosis and metabolic bone disorders
Disadvantage: A tumour will not be detected in
presence of same density tissue
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Medical imagery for the field therapist
CAT SCAN
ALSO USED TO ASSESS:
– Disk herniations
– Spinal canal in the presence of a fracture
– Spinal stenosis
– Spondylosis
Used for guidance in biopsies and
injections
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INDICATIONS FOR MRI
Musculoskeletal system
Soft tissue trauma and tumors
Ostéonecrosis
Spinal cord oedema
Disks
CONTRAINDICATED FOR:
–
–
–
–
Ferrous metal or mechanical devices implanted
Claustrophobia
Obesity
Severe pain
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Medical imagery for the field therapist
INDICATIONS FOR BONE SCAN
Indicates an abnormal process between
production and resorption of bone
Can reveal an early bone loss of 7% in
comparison to the conventional XX-Ray (25(25-30%)
Usefull to detect:
–
–
–
–
–
–
–
–
Stress #, Compound # , Scaphoid #
Periostitis
Primary and metastatic tumors
Various arthrides
Infections
Avascular necrosis
Metabolic bone disease
Any unexplained bone pain
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80% of imaging in MSK
conditions
di i
are b
basic
i
radiographs
(X--Rays)
(X
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Medical imagery for the field therapist
More information
Master class tutorials
http://radiologymasterclass.co.uk/tutorials/
musculoskeletal/x-musculoskeletal/x
ray_trauma_lower_limb/ankle_fracture_x-ray_trauma_lower_limb/ankle_fracture_x
ray.html#top
y
p_first_img
g
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SAFETY OF IMAGERY
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Medical imagery for the field therapist
RADIATION
Annual exposure: 3 mSv
mSv((mSievert
mSievert)) / year Radon,
airplane, ground, food, construction materials, cosmic
cities+
rays, altitude, cities
1 / 1000 individual will develop a cancer with an
exposition of 10mSv (low risk)
420 / 1000 other causes of cancer
Risk ↑ in children and ↓ in elderly
CAT SCAN +++
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Medical Imaging
App. dosage
Comparison with
environmental
(background)
Level of irradiation
MRI & US
0
0.001 mSv
-
0
Less than 1 day
☼
X-Rays, extremities
0.001 mSv
Less than 1 day
☼
X-Rays, vertebral
1.5 mSv
6 months
☼☼
X-Rays, Pelvis
0.1-1 mSv
10 days to 6 months
☼☼
CT, vertebral
6 mSv
2 years
☼ ☼☼
Bone Scan
1-10 mSv
2 years
☼ ☼☼
Bone density tests
DEXA
Adapté de http://radiologyinfo.org et ACR Appropriateness Criteria. Radiation
Dose Assessment Introduction
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Medical imagery for the field therapist
Understand the views
Anatomical position
Standard most common: AP / LAT / OBL
Specific projections
Routines p
provide maximum visualization
with minimal number of radiograph
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Ankle AP
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Medical imagery for the field therapist
Ankle LAT
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Ankle Mortise
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Medical imagery for the field therapist
http://www.wikiradiography.com/page/Ankle
+Radiographic+Anatomy
Ankle Links
Ankle - Protocols
A kl - Exposures
E
Ankle
Ankle Positioning
Ankle - AP
Ankle - Mortise
Ankle - AP Oblique ((Medial
Medial rotation)
Ankle - AP Oblique ((Lateral
Lateral rotation)
Ankle - Lateral
Ankle Radiographic Anatomy
Ankle - Paediatric
Ankle Miscellaneous
The Lateral Ankle Trap
Posterior Malleolus Fractures
Soft Tissue SignsSigns-The Ankle
Ankle Image Interpretation
Ankle Trauma 1 ((level
level 1-10)
Ankle Trauma 2 ((level
level 1-10)
Ankle Trauma 3 ((level
level 1-10)
Ankle Trauma 4 ((level
level 1 - 3)
Ankle Trauma 5 ((level
level 5 -10)
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CERVICAL AP
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Medical imagery for the field therapist
CERVICAL LAT
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CERVICAL OBL
Allows us to visualise the intervertebral foramen
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SPECIALIZED PROJECTIONS
Ski--line of patella
Ski
(intercondylar
Axial view (intercondylar
fossa))
fossa
Stress test
Weight bearing
y view ((GH))
Axillary
AP mouth open ((odontoid
odontoid))
Etc.
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Medical imagery for the field therapist
Whyy ?
To better comprehend the
implications
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Weber (Danis-Weber) classification of ankle fractures, based on
the location of the fibular fracture. The higher the fibular fracture,
the greater the likelihood for ankle mortise insufficiency
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Medical imagery for the field therapist
The AP and lateral views do not reveal
any obvious fractures.
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Subtle widening of the
medial aspect of the
distal fibular growth
plate (physis) on the
mortise view.
Comparative views
and/or stress views
would confirm that this
is a fracture versus a
normal growth plate
closure.
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Medical imagery for the field therapist
Stress fractures are not
insignificant
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Why imagery ?
T understand
To
d t d prescription
i ti
guidelines followed by physicians
and used for decision making.
making.
.
Nexus rules
Ottawa rules
Canadian C
C--Spine rules
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PRESCRIPTION PRINCIPLES
ALARA
– A as
– L low
– A as
– R reasonably
– A achievable
EQUATION benefits / RISK
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Line of conduct
Non rigid
Significant acute trauma
Significant pain / nausea
Positive osteophony test (+/
(+/--)
Deformation
Significant oedema
Pain on specific bony palpation / Crepitus
Positive tests: Vibration, stress ((varus
varus,, valgus,
valgus,
axial compression tests, ultrasound)
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Medical imagery for the field therapist
LINE OF CONDUCT
Pertinent history / Heard a crack
Reliability of history
Non traumatic bony condition of systemic
origin (Ex. cancer, osteoporosis …)
Atypical joint biomechanics
Atypical local palpation
Validated rules concerning acute trauma:
– Ottawa rules for the ankle and knee
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OTTAWA RULES
Rules established in 1996
To reduce of the number of XX-rays
prescribed by emergency room physicians
Have been established for the foot, the
ankle and the knee
Have been validated by many studies
worldwide
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Medical imagery for the field therapist
OTTAWA KNEE RULES
Characteristics of Patients Who Should
Undergo
g radiography
g p y After Knee Trauma
Age 55 years or older
Tenderness at head of fibula
Isolated tenderness of patella
Inability to flex knee to 90 degrees
Inability to walk four weightweight-bearing steps
immediately after the injury and in the
emergency department
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OTTAWA ANKLE RULES
Criteria for ankle radiographs
Bone tenderness at p
posterior edge
g of
distal 6cm or tip of medial or lateral
malleolus
Unable both to weight bear immediately
after injury and walk four steps in ER
department
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Medical imagery for the field therapist
OTTAWA FOOT RULES
Criteria for ankle radiographs
Bone tenderness at base of 5th metatarsal
Bone tenderness over navicular
Unable both to weight bear immediately
after injury and walk four steps in ER
department
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Medical imagery for the field therapist
CANADIAN CC-SPINE RULE
For alert and stable
t
ti t
trauma
patients
where cervical spine
injury is a concern
GCS = 15
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Predictable rules CCR
X-Rays are indicated if at least one high
risk criteria is present:
Age > 65
Dangerous mechanism
Paresthesia to extremities
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Medical imagery for the field therapist
High risk mechanisms
Fall from elevation > 3 feet (90cm) / 5 steps
Axial load to the head (diving, football, hockey)
MVA high speed (> 100Km/h)
MVA + rollover or ejection
Motorized recreational vehicles
Pedestrian struck by bicycle or collision with
bicycle
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C-Spine mobility
X-Rays are indicated if the patient is
45° to
unable to actively rotate neck to 45°
right and left.
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Medical imagery for the field therapist
Whyy ?
To better understand
the healing process
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CALCIFICATION
INTEROSSEOUS MEMBRANE
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Medical imagery for the field therapist
Why ?
Contribution in understanding
post--concussion symptoms of
post
neck origin (positional X-Rays,)
Spasm
Hypo / Hypermobility
Rotation, side bending
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LAT
SPACE BETWEEN ODONTOÏD / C1
3mm adultes
5mm enfants
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Medical imagery for the field therapist
FIXATION
ROTATION
C1/C2
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Why ?
To improve communication
T improve
To
i
clinical
li i l outcomes
t
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Medical imagery for the field therapist
TAKE HOME MESSAGE
Don’t trust the report / See the picture
Radiation is radiation; ALARA principle
Be curious, see the fracture to improve
your rehab outcome
Imagery is not only for pathology but also
for positional XX-Rays
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TAKE HOME MESSAGE
AT’s should know more about
medical
di l iimaging:
i
‰ For safety
‰ To answer clinical questions
‰ To improve their communication
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Medical imagery for the field therapist
TAKE HOME MESSAGE
Guidelines are for hospital
care but they can be an
important tool for the AT’s
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REMEMBER:
80% off imaging
i
i in
i MSK
conditions are basic
radiographs
First tool to add to your toolbox
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THANK YOU !
cberry@StadiumPO.com
514-259-4553
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REFERENCES
An Atlas of radiography for sports injuries, Jock Anderson
Bone and joint imaging,
imaging, Resnick
Fundamentals of orthopedic radiology
radiology,, Lynn N. McKinnis
Atlas d’anatomie radiologique et d’imagerie du corps humain
W i -Abrahams
Ab h
– Weir
WeirAccident and emergency radiology -A survival guide
– Raby
Raby--Berman
Berman--G de Lacey
Merrill’s atlas of radiographic positions and radiologic procedures
(tomes II--IIII-III)
– Ballinger
Acute Knee Injuries: Use of Decision Rules for Selective Radiograph
Ordering
– HOWARD B. TANDETER, M.D., and PESACH SHVARTZMAN,
M.D.
Ben--Gurion University of the Negev, Beer
Ben
Beer--Sheva
Sheva,, Israel , MAX
A. STEVENS, M.D.
University of Iowa Hospitals and Clinics, Iowa City, Iowa
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REFERENCES
http://www.acr.org/ Site internet de l’American College of Radiology pour les
critères de choix radiologique (pratique factuelle pour les ‘’‘’Appropriateness
Appropriateness
Criterias’’’’
Criterias
http://www
rad washington edu/academics/academic-sections/msk/teaching
http://www.rad.washington.edu/academics/academic
http://www.rad.washington.edu/academics/academicsections/msk/teaching-materials/online--musculoskeletal
materials/online
musculoskeletal--radiologyradiology-book/orthopedicbook/orthopedic-hardware.
hardware.
http://www.info--radiologie.ch
http://www.info
radiologie.ch..
http://www.radpod.org
http://www.radpod.org..
http://www.radpod.org
http://www.radpod.org..
http://www.xray2000.co.uk
http://www.xray2000.co.uk..
http://www.aafp.org/afp/991201ap/2599.html
http
://www.aafp.org/afp/991201ap/2599.html - December 1999
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